Iraqi Initiative of a Regional Comparative Breast Cancer Research Project in the Middle East

Breast cancer is the commonest malignancy among women in countries within the Eastern Mediterranean Regions (EMR). In Iraq, it comprises approximately one third of the registered female cancers. Other features that justify increasing efforts for breast cancer control in the EMR include the obvious rise in the incidence rates, the higher frequencies of younger ages and advanced stages at the time of presentation and the likely prevalence of more aggressive tumors resulting in high mortality/incidence ratios. At the level of national registration, most of the cancer registries of those countries lack data regarding tumour staging and mortality rates. In fact, within the hospital records, there is no proper documentation on critically important risk factors and clinical characteristics of the disease including stage distribution at the time of initial diagnosis, hormonal receptor status, proportion of women presenting with distant metastases, treatment modalities and survival rates. In an attempt to address the aforementioned information needs on the clinical profile of breast cancer patients, and emphasizing the role of research as one of the basic pillars in the adoption of the cancer control strategy, a “National Breast Cancer Research Program-NBCRP” was established in Iraq in 2009. In collaboration with the International Agency for Research on Cancer (IARC) and WHO, the Iraqi researchers developed a comprehensive information system for Iraqi patients diagnosed with breast cancer. Thereafter, that data base model was utilized to compare the demographic characteristics, clinicopathological presentations and management outcomes of breast cancer patients inhabiting selected countries in the EMR (so far Iraq, Jordan, Lebanon and Egypt are included). BACKGROUND Globally, breast cancer is the most common cancer among women, comprising 23% of the female cancers [1]. It is also the leading cause of cancer-related deaths. The case fatality rates are highest in low resource countries [1,2]. Although substantial improvement in survival from this disease has been reported in high-income countries such as the USA, the risk continues to increase and survival rates in middle-and low-income countries remain low. According to Globocan [1], in 2008 the total number of newly diagnosed breast cancer cases worldwide was 1.38 million, and the total number of deaths from the disease was 458,367; 59% of the mortality rates were recorded in less developed regions of the world. Within the Eastern Mediterranean Region (EMR), according to WHO mortality estimates, cancer is the fourth ranked cause of death; succeeding cardiovascular diseases, infectious/parasitic diseases and injuries [3-5]. The largest increase in cancer incidence among the WHO regions in the next 15 years is likely to be in the EMR [6], where breast cancer is reported as the most common type of female malignancy in almost all national cancer registries [1]. Significance of initiating breast cancer control programs in the EMR In addition to being the most important cancer, there are other features that justify increasing efforts for breast cancer control within the EMR. These include the obvious rise in the incidence rates, the higher frequencies of younger ages and Special Issue on Breast Cancer Therapeutics Central Alwan (2014) Email: [email protected] J Cancer Biol Res 2(1): 1016 (2014) 2/4 advanced stages at the time of presentation [7-12] and the likely prevalence of more aggressive tumours resulting in greater fatality rates [1,11,13]. These factors lead to low five-year survival rates (10-50%) from breast cancer in many lowand medium-resource countries (LMC) as compared to more than 85% 5-year survival in high-income countries [1,14]. Information on the putative risk factors for breast cancer and the clinical profile of patients with the disease in terms of clinical stage at presentation, proportion of cancers with regional lymph node metastases, estrogen receptor positivity, treatment patterns and survival outcomes are of utmost importance in the context of breast cancer control in the EMR [7,15]. Two different approaches have to be undertaken to address these two distinct information needs: Properly designed analytical studies such as case-control or cohort studies are needed to address breast cancer risk factors. On the other hand, well conducted descriptive studies can address the pathological, clinical and survival outcome profiles in breast cancer patients. At the level of national registration, most of the cancer registries of countries belonging to the EMR lack data regarding stages of the disease at presentation [7], age-specific incidence and survival rates. Furthermore, within the hospital records, there is no proper documentation on critically important clinical factors such as tumor size, nodal status, stage distribution at the time of initial diagnosis, hormonal receptor status, proportion of women presenting with distant metastasis, proportion of patients treated with radical mastectomy versus breast conservation surgery, other prevailing treatment modalities (including radiotherapy, chemo and hormonal therapies) and twoand five-year survival rates. A critically important factor in clinical research is an up to date medical record which is often underemphasized. Collecting good quality data from breast cancer patients in LMC depends upon documentation of clinical findings accurately in medical records in cancer treatment centers [2,3,5,14]. In Iraq, breast cancer is the most common type of malignancy among the Iraqi population in general. It accounts for approximately one third of the registered female cancers according to the latest Iraqi Cancer Registry [16] which shows a trend for the disease to affect younger age groups [9,16]. Within the last two decades, there has been an obvious increase in the incidence rates of breast cancer, which became one of the major threats to Iraqi female health. Regrettably, many cases in Iraq tend to be diagnosed at advanced stages [9] with a prevalence of poorly differentiated pathological grades; illustrated in DNA nuclear aneuoploidy and thus yielding a mortality incidence ratio equivalent to 60% [1,13]. In one of the studies that was designed to review the demographic characteristics and clinico pathological presentation of Iraqi patients complaining of breast cancer [9], it was observed that approximately one third were diagnosed at age (40–49 ) years; 71.9% came from urban areas; and 75% were married. History of lactation was reported in 63.1% and hormonal therapy in 29%. Positive family history was recorded in 16.2%. Although the lump was detected by the patient herself in 90.6% of cases, only 32% sought medical advice within the first month. Accordingly, 47% of those patients presented in advanced Stages (III and IV). The main histological type was Invasive Ductal Carcinoma (IDC), in which pathological changes signifying Grades II and III were observed in 56.6% and 39.9% respectively. DNA analysis, using quantitative image cytophotometry showed that 80.3% of the carcinomas were aneuploid [13]. Estrogen and Progesterone Receptor positive tumour contents were demonstrated in 65.1% and 45.1% respectively, while Her-2/ neu positive expression was displayed in 46.4% of the examined cases. Overall, triple negative mammary carcinomas were displayed in 16.7% of the cases. In a more recent survey [17] that evaluated the knowledge, attitude and practice towards breast cancer and breast selfexamination (BSE) among a sample of educated Iraqis affiliated with two major universities, it was documented that almost half of the participants had a low knowledge score (< 50%). Although 90.9% had heard of BSE, only 48.3% practiced the technique. The findings of those two studies clearly justify the demand for increasing efforts to establish comprehensive breast cancer control programs in Iraq and the region. Introducing a comprehensive information system data base on breast cancer control in iraq and the EMR In an attempt to address the aforementioned information needs on the clinical profile of breast cancer patients, and emphasizing the role of research as one of the basic pillars in the adoption of the cancer control strategy, a “National Breast Cancer Research Program-NBCRP” was established in Iraq in 2009. In collaboration with the International Agency for Research on Cancer (IARC) and WHO, a comprehensive information system was developed for Iraqi patients diagnosed with breast cancer. Thereafter, that data base model was utilized to compare the demographic characteristics, clinicopathological presentations and management outcomes of breast cancer patients inhabiting selected countries in the EMR (so far Iraq, Jordan, Lebanon and Egypt are included).